Provider Demographics
NPI:1922611078
Name:KHONYONGWA, EDWIN CHARLES (LALFA, LPN)
Entity Type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:CHARLES
Last Name:KHONYONGWA
Suffix:
Gender:M
Credentials:LALFA, LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5153 SPINNAKER LN
Mailing Address - Street 2:
Mailing Address - City:KING GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:22485-3163
Mailing Address - Country:US
Mailing Address - Phone:571-354-9781
Mailing Address - Fax:703-910-6907
Practice Address - Street 1:7829 DOLLEYS CT
Practice Address - Street 2:
Practice Address - City:KING GEORGE
Practice Address - State:VA
Practice Address - Zip Code:22485-7085
Practice Address - Country:US
Practice Address - Phone:540-318-3940
Practice Address - Fax:703-910-6907
Is Sole Proprietor?:No
Enumeration Date:2020-08-28
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002092297164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1732000897OtherNURSING HOME ADMINISTRATOR
VA0002092297OtherLICENSED PRACTICAL NURSE
VA1706001017OtherASSISTED LIVING ADMINISTRATOR
VA1401150271OtherNURSE AID